Privately-Administered Refugee Medical Assistance through a Medical Replacement Designee
Policy Letter 19-04
February 19, 2019
The purposes of this Policy Letter are to clarify the Office of Refugee Resettlement's (ORR) requirements and expectations for: 1) the structure of the privately-administered Refugee Medical Assistance (RMA) program; 2) RMA responsibilities of the Medical Replacement Designee (MRD); 3) private RMA health coverage and plan administration; and 4) the agencies funded to assist with RMA eligibility determination at the state and local level.
Purpose and Structure of the Privately-Administered RMA program
The purpose of the RMA program is to provide medical assistance under section 412(e) of the Refugee Act to refugees who are ineligible for Medicaid. The privately-administered RMA program aims to fulfill this purpose in states where state governments have chosen to withdraw from administering all or part of the program. ORR regulations at 45 CFR §400.301(c) authorizes the Director of ORR to designate a replacement designee or designees to administer the provision of assistance and services to refugees in these states. For more information about replacement designees, see Policy Letter #18-03. The privately-administered RMA program may also provide medical assistance to refugees who are ineligible for Medicaid in other states where there may be a need to operate this type of program.
The privately-administered RMA program is a multi-state operation administered by one agency designated by ORR as the MRD. To ensure refugees who are ineligible for Medicaid have access to medical assistance, ORR will continue to assess, invite, and approve an MRD to maintain and expand the program as necessary. Expansion of the program into states not already approved for operation requires ORR’s invitation to develop a plan and budget estimate for expansion, the MRD’s submission of a plan and budget estimate, and ORR’s review and approval of the plan and budget estimate.
RMA responsibilities of the Medical Replacement Designee
The MRD must adhere to the same regulations and policies that apply to states that administer ORR benefits, unless otherwise exempted in 400.301(c). The MRD will have authority regarding the oversight and coordination of the privately-administered RMA program in all areas of approved operation. This includes responsibility for ensuring compliance with federal regulations and policies concerning the scope of RMA services and eligibility requirements. The MRD will establish policies and procedures for RMA eligibility determinations and for the provision of medical services to refugees. Policies and procedures developed by the MRD must be clearly established and reasonable for relevant agencies to adhere to.
The MRD must establish formal agreements with agencies funded by ORR to assist with RMA eligibility determination. Formal agreements must outline agreed-upon roles and responsibilities of the MRD and the agency funded by ORR to assist with RMA eligibility determination, including data collection and sharing in accordance with federal regulations and policies.
The MRD must use OMB-approved standard forms for state-administered programs to report budget, expenditure, and performance outcomes for the overall program as well as provide a breakdown by state as applicable and as directed by ORR.
In states where the MRD is offering ORR-funded Unaccompanied Refugee Minor (URM) health coverage to qualified URMs, the MRD must also follow additional policies set by ORR.
Requirements for health coverage and plan administration under private RMA
The scope of medical services must adhere to 45 CFR §400.105 in each state of operation. The eligibility requirements must adhere to 45 CFR sub-part G in each state of operation. Overall Cash and Medical Assistance (CMA) administrative costs and other administrative costs for each state of operation must follow federal regulations and ORR policies.
The MRD must administer a self-funded plan or a more cost-efficient alternative that operates in accordance with regulations. Alternative options to a self-funded plan must be reviewed and approved by ORR before implementation. ORR will take into consideration the impact of the disruption in services for refugees, costs, and regulatory requirements. The MRD must negotiate reimbursement rates for medical services that align with Medicaid rates in each state of operation. If Medicaid rates cannot be agreed upon with a certain provider and if the provider offers necessary specialty services or is in an area with a shortage of providers, the MRD may negotiate the lowest rates possible. The MRD may obtain stop-loss coverage as an additional cost-containment measure.
The MRD may contract with a third party administrator (TPA) to administer the self-funded plan with oversight from the MRD. Significant changes to the administrative structure and/or key agencies involved in the administration of the self-funded plan must be reviewed and approved by ORR prior to implementation. ORR will take into consideration the impact of the disruption in services for refugees, costs, and regulatory requirements.
Agencies funded to assist with RMA eligibility determination
To ensure RMA remains integrated in the services offered by the overall refugee program in the state, ORR may provide funding to authorized agencies such as Replacement Designees to assist with the initial RMA eligibility determination. Obtaining authorization and responsibility for this function requires ORR’s invitation to develop a plan and budget estimate, the agency’s submission of a plan and budget estimate, and ORR’s review and approval of the plan and budget estimate.
These authorized agencies will be responsible for managing and monitoring any sub-contracts with local resettlement agencies assisting with RMA eligibility determinations. They are required to follow the policies and procedures established by the MRD to ensure adherence to federal regulations regarding the eligibility determination, enrollment, and the provision of services in the RMA program.
The MRD and these agencies are expected to collaborate to ensure the adequate and timely delivery of RMA coverage to refugees. These agencies must have formal agreements with the MRD outlining agreed-upon roles and responsibilities of each agency, including data collection and sharing in accordance with federal regulations and ORR policies. ORR encourages these authorized agencies and the MRD to conduct joint monitoring activities of local resettlement agencies sub-contracted to do initial RMA eligibility determination to ensure compliance with RMA policies and procedures.
Jonathan H. Hayes
Office of Refugee Resettlement